Laparoscopic vs Open Appendectomy

Acute appendicitis is one of the most common surgical emergencies and appendectomy remains one of the most frequently performed emergency abdominal surgical procedures. Open appendectomy has traditionally been used as the standard operative approach, while laparoscopic appendectomy has increasingly been adopted because of its minimally invasive nature and potential postoperative advantages. Surgical site infection is an important postoperative complication of appendectomy because it can cause additional morbidity, delay wound healing and recovery, increase the need for postoperative treatment and follow-up, and potentially prolong healthcare utilization. The frequency of surgical site infection may vary according to the operative approach, patient characteristics, disease severity, operative technique, and perioperative management.

The present randomized controlled trial was conducted to compare the frequency of superficial surgical site infections following laparoscopic appendectomy and open appendectomy in patients presenting with acute appendicitis. The study was conducted in the Department of Surgery, Bahawal Victoria Hospital, Bahawalpur, over six months, from 24 January 2026 to 23 July 2026. A total of 276 patients were included, with 138 participants allocated to each group.

The study population consisted of patients aged 15 to 60 years of either sex who presented with acute appendicitis and fulfilled the predefined eligibility criteria. Acute appendicitis was diagnosed on the basis of right iliac fossa pain with a visual analogue scale score of 3-10, positive rebound tenderness on clinical examination, and a white blood cell count greater than 10,000/mm³. Patients were eligible if the duration of symptoms was 48 hours or less. Both elective and emergency appendectomies were included.

Patients were excluded if they had generalized peritonitis, perforated appendicitis, uncontrolled diabetes mellitus, immunosuppression, previous abdominal surgery, chronic renal failure with serum creatinine above 1.5 mg/dL, or chronic liver disease with serum bilirubin above 2 mg/dL.

After approval of the study synopsis and institutional ethical approval, eligible patients were enrolled after obtaining informed written consent. Baseline demographic and clinical information was recorded using a structured data collection proforma. Variables included age, sex, duration of symptoms, height, weight, body mass index, obesity status, residence, type of surgery, socioeconomic status, diabetes mellitus, and duration of surgery.

A body mass index greater than 27 kg/m² was considered obese and 27 kg/m² or below was considered non-obese. Residence was categorized as urban or rural according to documented residential address. Socioeconomic status was categorized according to monthly household income into poor class (≤20,000 PKR), middle class (21,000-40,000 PKR), and upper class (≥41,000 PKR). Diabetes mellitus was recorded on the basis of a known history of diabetes with ongoing treatment and controlled fasting blood glucose below 126 mg/dL on two consecutive measurements.

Participants were randomly allocated in a 1:1 ratio using a lottery method. Group A underwent laparoscopic appendectomy, while Group B underwent open appendectomy. All participants received prophylactic antibiotics according to the study protocol, and the duration of postoperative intravenous and outpatient antibiotic therapy was recorded. All operations were performed by the same consultant surgeon with at least five years of post-fellowship experience to maintain consistency in operative technique.

Patients were followed for seven postoperative days. During follow-up, the surgical wound was assessed for superficial surgical site infection and findings were recorded on the structured proforma. The primary outcome was the frequency of superficial surgical site infection within seven postoperative days. Superficial SSI was defined according to the predefined clinical criteria. A patient was considered to have superficial SSI if purulent wound discharge, redness around the wound or stitches, or postoperative fever exceeding 100°F was observed within seven days following surgery. The outcome was recorded as present or absent.

Demographic and clinical characteristics were recorded for comparison between groups. These included age, sex, duration of symptoms, BMI and obesity status, residence, type of surgery, socioeconomic status, diabetes mellitus, and duration of surgery. Stratified analysis of superficial SSI was planned according to these characteristics.

The sample size was calculated using a 5% level of significance and 80% power, based on an anticipated superficial surgical site infection rate of 20% following laparoscopic appendectomy and 35% following open appendectomy. A total of 276 participants were included, with 138 in each group. Consecutive sampling was used for participant enrollment, followed by random allocation using the lottery method.

Operative duration was recorded for each participant and categorized into short and long duration according to the predefined study categorization for stratified analysis.

Statistical analysis was performed using SPSS version 25.0. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed continuous variables were expressed as mean ± standard deviation, while non-normally distributed variables were presented as median with interquartile range. Categorical variables were summarized using frequencies and percentages. The independent-samples t-test was used for normally distributed continuous variables, while the Mann-Whitney U test was used for non-normally distributed variables. Categorical variables were compared using the Chi-square test or Fisher's exact test, as appropriate.

The primary outcome was compared between the laparoscopic and open appendectomy groups using the Chi-square test. Stratified analyses were performed according to age group, sex, duration of symptoms, BMI category, residence, type of surgery, socioeconomic status, diabetes mellitus, and duration of surgery. A p-value of ≤0.05 was considered statistically significant.

The study specifically focused on superficial SSI occurring during the first seven postoperative days and did not combine superficial infection with deep or organ/space surgical site infection. The study was conducted after institutional ethical approval and approval of the study synopsis. Written informed consent was obtained from all participants before enrollment. Participant demographic and clinical information was recorded using a structured proforma, and postoperative wound findings were documented during the seven-day follow-up period.

Inclusion criteria

• Patients aged 15-60 years of either sex.
• Patients diagnosed with acute appendicitis according to the predefined operational definition and undergoing appendectomy.
• Duration of symptoms less than 48 hours.
• Both elective and emergency appendectomy cases.

Exclusion criteria

• Patients with generalized peritonitis or perforated appendicitis.
• Patients with significant comorbidities, including uncontrolled diabetes mellitus or immunosuppression.
• Patients with a history of previous abdominal surgery.
• Patients with chronic renal failure, assessed on history and medical records, with serum creatinine >1.5 mg/dL.
• Patients with chronic liver disease, assessed on history and medical records, with serum bilirubin >2 mg/dL.